A 6-year-old patient with Ewing sarcoma at L4 who was treated with total en bloc spondilectomy (TES) through a posterior-only approach. During the dissection of the anterior L4 body, there was uncontrollable bleeding from an unknown origin, which needed packing, massive transfusion, and urgent laparotomy. A median sacral artery (MSA) rupture was identified as the cause of this massive bleeding. Eventually, the patient was successfully stabilized.
To our knowledge, this is the first reported intraoperative bleeding of the MSA related to a lumbar TES through posterior-only approach. This life-threatening complication should be considered when planning for this type of surgery.